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A_RN A_RN (New Member) New Member

Post-Extubation Policy

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Hi,

I work in a small regional hospital and recently realized that our ICU has no policy for extubation or the immediate care after. I am trying to develop a policy of best practices so that I can develop one.

I am just wondering if anyone would be willing to share policies from their facilities?

Thanks,

AG

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Where I work we put them on pressure support, make sure their tidal volumes are good and they are alert enough to follow commands for at least 4 hours or so (depends on patient condition and length of intubation). If the MDs give the go ahead to extubate then we call respiratory therapy and we check for a cuff leak and then extubate to 40% ventimask and leave them on that for about 2 hours. If they are doing well after 2 hours then we move them to nasal cannula and also start dysphagia screening with ice unless there are contraindications.

Also, do not forget to consider whether you will leave the NGT in or take it out? If you think the patient will fail swallowing then leave it in so you will not need to put another one in. Neuro patients and the elderly may need more time to regain swallowing abilities and may need tube feeds/meds but are okay to be extubated.

Edited by KeepinitrealCCRN
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Similar to the above post, we stop sedation and check alertness and command following and put them on spontaneous/pressure support for at least an hour. Sometimes an hour is all an agitated, non-sedated patient who's eager to get the tube out can stand, but usually we go longer if tolerated. Then RT does a few tests involving NIF, tidal volumes, cuff leak, etc. Then if physician is okay with it we go ahead and extubate. We will go straight to nasal cannula and increase oxygen delivery if need be.

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Ventilation requirements are that pt. needs to be on Spont mode (no brainer really). Grade of airway should be noted in case of reintubation.

PS 10 or less, PEEP 10 or less, Fi02 30% or less.

Assess airway, has spont cough (strong) and gag. Has a audible cuff leak.

Able to follow commands, strong enough to lift head off the pillow and able to take large Vt when instructed.

Also have a decent pre extubation ABG.

Extubate onto varying oxygen np, HM, HighFlow (my unit is quite varied in pts). Do a post extubation ABG 30mins after and obviously closely monitor.

That's what we have a general rule. Obviously dependingon your unit there maybe exceptions. We have major neuro cases which don't always go completely to protocol prior to extubation, but the intensivist has clearly documented

 

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Are you working with your department of Respiratory Therapy?

There is no need to re-invent the wheel and doing so risks missing some big things. As no one that has responded has (apparently) attached a detailed pdf or word document of a detailed policy, I'd steer clear of All Nurses for such an important undertaking. 

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Do you have a respiratory therapy department?  There are definitely evidence-based best practices for assessing for extubation readiness, extubation, and post-extubation care.

Extubation readiness: able to follow commands, off most sedation, minimal use of vasopressors, PEEP less than 8 cm H2O, FiO2 less than 0.5, a pressure support trial with minimum settings while achieving adequate tidal volumes.

PS trial means different things in different facilities.  A true PS trial would be a PEEP of 3-5 cm H2O, and a PS of 0-3 cm H2O.

The patient needs to have a significant leak when the cuff is deflated, not be producing excessive secretions, and able to manage those secretions.

Post extubation depends on the patient's needs.  Many patients are fine on room air or 1-4 LPM NC.  Some people will extubate to HHFNC, CPAP, or BiPAP.  Some patients need a dose or two of racemic epi to manage swelling.  And of course, some patients will fail extubation and need to be reintubated which is absolutely not a failure on the part of the RT/RN/MD.

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